ADRE Lic Form LI-226 Broker Can Exp Verif 8/2019
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DEPARTMENT OF REAL ESTATE (ADRE)
North 15th Avenue, Suite 201, Phoenix, Arizona 85007
BROKER CANDIDATE EXPERIENCE VERIFICATION (FORM LI-226)
Review Guidelines/Instructions BEFORE submitting this form.
Print Candidate Name as it appears on Real Estate License:
Job Title with current employer:
*Must be initialed by Designated (Principal) Broker
I affirm by my signature and initials below that my representations herein are true and have the actual experience stated.
BROKER INFORMATION – To be completed by each Employing Broker and/or out of state Designated Broker(s).
Print Designated (Principal) Broker Name as it appears on Real Estate License:
Entity (Brokerage) Legal Name & DBA:
Entity (Brokerage) Current Mailing Address:
Designated (Principal) Broker Email Address:
Alternate Phone Number
Additional statement is attached.
DESIGNATED (PRINCIPAL) BR
I affirm by my signature below that I am the Designated (Principal) Broker for the brokerage named above and that I/the brokerage
employed the Candidate named above within the past five (5) years, as indicated by the Start Date and End Date. To the best of my
knowledge and belief, the Candidate engaged in activities for the stated actual full time hours monthly, for which an active license was
required (check applicable license type below).
Real Estate Cemetery
actual full time hours worked (monthly) Broker's Initials
Designated (Principal) Broker Signature
Authorized ADRE Signature